MAUDE Adverse Event Report: HOYA SURGICAL OPTICS, INC. PREVUE C; INTRAOCULAR LENS

Model Number	PREVUE C (+19.50 D)
Medical Device Problem Code	Material Split, Cut or Torn (4008)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	02/08/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This initial emdr is being submitted to fda as a reportable event that occurred in the usa.Haptic damage is indicated as a potential malfunction related to the iol, as covered under the warnings section of the product's instructions for use (ifu).Manufacturer's codes for: type of investigation, findings, and conclusion are pending device return and completion of product investigation.Once the product investigation is completed, a follow-up report will be submitted to fda which will include the manufacturer's codes for type of investigation, findings, and conclusion.
Event or Problem Description
Broken haptic during use.Trailing haptic broke during insertion.The lens was removed, and a backup lens placed without issues.Patient impact: intra-operative explantation.Patient health not impacted.
Additional Manufacturer Narrative
This follow-up #1 emdr is being submitted to fda for a reportable event that occurred in the usa.Note: delayed emdr submission was due to fda esg webtrader account system software issues, per fda esg help desk ticket # 352650 (and subsequent ticket # 359662).Hoya due diligence is documented under internal issue-0807.The report includes corrected information and additional information not available/included in the initial report.Corrected information: d3 - corrected address; h3 - corrected to yes.Additional information: d9 - added date of return; g1 - added contact info; g6 - type of report - noted as follow-up #1.H2 - type of follow-up - noted for corrected information and additional information.H6 - added codes for manufacturer's investigation: type; findings; and conclusion.Portions of the product were returned to the manufacturer.The investigation was conducted, with the methods and results as noted below.Only iol was available for investigation.Appearance check result was consistent to reported information.No abnormalities were found in production and inspection records of the product.(serial no.: (b)(6); model: prevue c).We also confirmed there were not any abnormalities on the loop pull strength test record of the material lot.(sotj-g115-07) the exact root cause of the event was not determined.However, based on available information, we believe this event was not caused by our product quality.Capa-22-0009 has been initiated for "damaged haptic" complaints.
Event or Problem Description
Broken haptic during use trailing haptic broke during insertion.The lens was removed, and a backup lens placed without issues.Patient impact: intra-operative explantation.Patient health not impacted.

• Brand Name: PREVUE C
• Common Device Name: INTRAOCULAR LENS
• Manufacturer (Section D): HOYA SURGICAL OPTICS, INC.; 110 progress; suite 175; irvine CA 92618
• Manufacturer (Section G): HOYA MEDICAL SINGAPORE PTE LTD; 455a jalan ahmad ibrahim; singapore, singapore 63993 9; SN 639939
• Manufacturer Contact: goutham pendyala ; 110 progress; suite 175; irvine, CA 92618 ; 9093896317
• MDR Report Key: 16509078
• Report Number: 3006723646-2023-00035
• Device Sequence Number: 17557691
• Product Code: HQL
• UDI-Device Identifier: 10757770564146
• UDI-Public: 10757770564146
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: P080004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 02/08/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 01/31/2024
• Device Model Number: PREVUE C (+19.50 D)
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/08/2023
• Supplement Date Received by Manufacturer: 02/08/2023
• Initial Report FDA Received Date: 03/08/2023
• Supplement Report FDA Received Date: 06/07/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/31/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown